What is to be concerned of cardiovascular field in Asian region?

Kaul-UpendraDr. Upendra KAUL
Executive Director & Dean: Cardiology
Fortis Escorts Heart Institute and Fortis Hospital
Vasant Kunj, New Delhi


I. The Scope, Topics, Criteria of AsiaIntervention

Clinic: The first volume of AsiaIntervention in 2016 was launched in this January AsiaPCR. As the Editor-in-chief of this young journal, please introduce what is the scope of AsiaIntervention?

Dr. Upendra KAUL: AsiaIntervention has a really important theme – it is a journal meant specifically for Asian readers. Asia is a large region – from Southeast Asia, Pakistan, Bangladesh going to Far East Asia with Malaysia, Indonesia… With two-thirds of mankind living in Asia, the needs of the readers are different from the needs of readers of Western journals, especially in terms of carrying out intervention procedures, whether it is in the coronary or structural heart disease.

As such, in AsiaIntervention we strive to address issues specific to Asia. For instance, in Asia, doctors face a limitation of resources. In turn, the challenges for doctors in Asia are different as compared to their peers in Western Nations. Here doctors must utilize innovative methods such as balloons, stents, or guide wires in order to find the best method of achieving successful results with resource limitations. We use these in a large number of cases. Given this theme, I feel that this journal can propagate the approaches of key opinion leaders in this region to these procedures with our unique constraints. I think that is the most important part of this journal; it is specific to the needs of the Asia region.

Clinic: What kinds of topics are exhibited by this journal?  

Dr. Upendra KAUL: The topics will be focused on the problems that are specifically seen in the Asian region. Coronary heart disease, for example, is one of the most important diseases, it will most definitely be included.

In addition to that, there will be a focus on diseases that are not so often heard of but are quite often seen in our day-to-day experience in this region. These include rheumatic heart disease or non-specific aortitis, which is seen in both India, China, and the Far East. The journal includes innovative methods of treating these diseases that are more specific to the Asia region.

It is important to publish and write articles concerning these issues to increase awareness. Such articles will help doctors to identify that, symptoms such as severe hypertension or consequences of narrowing of important arteries are not only to be treated with medicine alone but there are interventional techniques to treat them better. It is important to highlight the fact that the techniques may differ from those used in routine angioplasty. This journal could really serve as an important source for such information.

Clinic: What criteria are utilized in choosing the articles that are approved?

Dr. Upendra KAUL: The current process that we operate under is that the article comes from the Chief editors . We then examine whether it is of use or has sufficient interest. Once we determine whether it has sufficient interest, it is sent to the reviewers. I, personally, send it to the reviewers who have a solid knowledge of that particular hospital, article, or technical aspect of the article. I find this method to be very successful for us.

II. Attention on India – A Rapid Development in Cardiovascular Field

: If we could turn our attention now to India. We know the cardiovascular field in India is developing very quickly. How are you addressing this rapid development in India?

 Dr. Upendra KAUL:

A/ Diabetes

To many, India is considered to be the capital of diabetes in the world and, as we know, diabetics are very prone to vascular diseases – not only coronary disease but also diseases of the peripheral arteries, stroke etc. As such, the cardiovascular filed in India has developed rapidly out of need. In turn, we need to focus on the therapies that will provide solid solutions for diabetics. For example, in regards to coronary artery disease, bypass surgery is supposed to be a better way than angioplasty to treat multi-vessel disease. While bypass surgery is not well accepted. If we can have non-surgical methods of nearly equal effectiveness, they would be welcome in India.

B/ Personal Contribution in Trial of Everolimus vs. Paclitaxel Eluting Stent

I personally have been working on this as a lead investigator along with 48 different  Indian centers. I presented a trial comparing two kinds of stents – paclitaxel stent purportedly good for diabetics and everolimus eluting stent (TUXEDO- INDIA). The results showed that the everolimus eluting stent was superior, which was contrary to the meta-analysis from the European studies. In the case of India, especially, we should not get bogged by older studies such as the Freedom Study that states the superiority of bypass surgery; instead, we should begin looking at new studies comparing new generation stents with bypass surgery,in comparison to older studies.

C/ Future solution by Cost-effective Stents

Also, to further develop the field, we should focus our efforts in India on producing cost-effective stents as they do in China. Some stent companies in India produce everolimus eluting stents of good quality with good polymers that dissolves, and at a much lower cost – one-fourth of the usual cost. Such products are especially promoted for a patient who requires three or four stents, thus the surgery and angioplasty can be of equality to the patient.

Dr. Upendra KAUL: We should promote that intervention is not the end of the therapy. Following the placement of a stent, a lot of remains to be done. Drugs are extremely important; cholesterol reduction and blood pressure reduction are important. Cardiovascular treatment has to be done in a holistic way. I think that AsiaIntervention promotes this type of holistic approach. Many intervention cardiologists believe that completing the intervention is the end, but that is not the case. If one does not continue with good medical treatment and counsel the patient, the result will not be as successful.

III. Bridge the Gap and Provide Opportunities in Asian Region

Upendra KAUL: That is an important, yet difficult to answer question. We do not expect AsiaPCR to make less developed countries more developed. However, we do try to have programs and smaller meetings in these countries to assist with their needs. It is not easy for many doctors from less developed nations to acquire a sponsor and travel to Singapore. Drug companies and device companies also select those people who are good customers – people who are learning and do not have much backing from these sponsors can not avail of these meetings.

If AsiaPCR were to have satellite meetings in some of these countries as a one-day meeting, we will be able to help these doctors more. The Course Director from that region will help them identify some of the centers in smaller cities and choose the faculty from the region in addition to some big name people to join in a meeting there. If we could do this two or three times a year, it would be one method of spreading the message of AsiaPCR to people who are willing to learn but cannot physically attend our larger meetings.

Clinic: In the future, which field should AsiaPCR give more concern?

Dr. Upendra KAUL: I think the AsiaPCR should start putting more emphasis on structural heart disease now, as coronary heart disease and angioplasty have become quite routine in recent years. We have specific guidelines on which procedure or equipment to use, which stent to deploy in certain cases. The field of coronary heart disease and angioplasty have become well developed, and coronary teachings have been discussed for nearly 20 years. In turn, the intellectual and medical discourses in the field have started to become repetitive, in a sense.

As such, I feel the focus should shift to aortic valve placements, mitral repair, left atrial appendage closure etc. – these are the newer fields of cardiovascular intervention. Because they are more recent fields, people are very keen to learn about them..